JACKSON YOUTH PROGRAM 2022 APPLICATION

Medical Information

Insurance Information
Policy Number*
Name of Health Insurance*
Primary Care Physicaian Name*
Hospital *

Name of Affiliated Hospital

Street Address

CityZip Code

State
Phone Number*
Please enter a valid phone number.

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

	Medical Problem	Treatment	Paramedic Call? (Yes or No)
Medical condition#1
Medical condition#2
Medical condition#3
Medical condition#4

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).
Medical Emergency Parent's/Guardian's Initials*
I understand that JACKSON YOUTH PROGRAM will not be responsible for the medical expenses incurred, and that such expenses will be my responsibility as parent/guardian.
Medical Expenses Parent's/Guardian's Initials*
Signature*

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Medical Information
[PLEASE ATTACH MOST RECENT PHYSICAL/IMMUNIZATION FORM TO THIS APPLICATION]

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Is this youth presently being treated for an injury or sickness?*
If yes, explain:
Is this youth allergic to any type of food or medication?*
If yes, explain:
Does youth have an Epipen?*
If yes Epipen must be provided
Does youth require a special diet?*
If yes, explain:
Does youth have any behavioral or emotional struggles that we should know about?*
If yes, explain:
Is youth currently taking any medication?*
If yes, please complete attached medication consent form and an authorization for self -administration by child’s physician
If yes, please explain what the medication is for:

Commonwealth of Massachusetts Department of Early Education and Care

MEDICATION CONSENT FORM 606 CMR 7.11 (2)(b)
Medication Consent Form including authorization for self - administration completed by youth's physician must be completed prior to youth beginning. Please complete and upload to this application or mail completed form to JacksonYouthProgram.org
File Upload

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Please list youth's strengths, hobbies and areas of interest:*
Please list areas youth needs improvement in:*

Terms of Agreement
I am aware that JACKSON Youth Program requires a $35 non-refundable deposit to hold a slot for a session. All sessions must be paid in full one week prior to start date. The $35 deposit will be put towards the session cost.
Terms of Agreement Deposit Parent's/Guardian's Initials*
Photos
I hereby give permission for my child to be photographed during JACKSON Youth Program. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. Childrens’ photos and quotes may be used for publicity purposes I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of JACKSON Youth Program.
Terms of Agreement Photos Parent's/Guardian's Initials*
Transportation
I hereby give permission for the transportation of my child for official JACKSON Youth Program activities by modes of transportation agreed to by the program organizers.
Terms of Agreement - Transportation: Parent's/Guardian's Initials*
I am aware that JACKSON Youth Program and its co-organizers are not responsible for lost or damaged personal property.
Terms of Agreement - Lost or damaged personal property: Parent/Guardian Initials *
Tearms of Agreement Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Terms of Agreement Parent/Guardian Signature*

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Date

MonthDayYear
Date
Printed Name of Parent/Guardian*

WALKER AUTHORIZATION FORM
I certify that Youth's First Name Youth's Last Name WILL WILL NOT walk unaccompanied to/from JACKSON Youth Program.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Walker Authorization Form Parent Signature*

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Date

MonthDayYear
Date
Printed Name of Parent/Guardian*
Should be Empty:

JACKSON Youth Program

Session Selection

Youth Information

Parent Information

Emergency Contact

Medical Information

Medical Information

Commonwealth of Massachusetts Department of Early Education and Care

Terms of Agreement

Photos

Transportation

WALKER AUTHORIZATION FORM